The words "crisis" and "health care" follow each other in sentences so often in South Africa that most citizens have grown numb to the association. Clinicians, health managers and public health experts have been talking about a crisis in access to health care for more than half a century, and the advent of democracy has not alleviated the situation.
South Africa's inability to adequately respond to its many crises is also the result of a national healthcare system designed to provide treatment rather than prevention. The over-dependence on hospital-based care in South Africa not only makes the healthcare system expensive and inefficient, but also precludes much-needed investments in primary and preventative care. Health minister Dr Aaron Motsoaledi honestly conceded that the public health system faces 'very serious challenges'(Philip 2009).
In this review I describe the crisis in childcare and its consequences for the health of children, characterise the underlying reasons for the crisis, examine current interventions and explore some medium and longer term solutions.
How severe is the crisis?
It is not surprising that the public's perception of health services are often determined by stories about the care offered to children presented in the media. For instance, in one week in May 2010, two stories dominated newspaper and media headlines in Gauteng. One was the death of seven newborn infants and the infection of 16 others as a result of a virulent infection (subsequently identified as a norovirus) acquired by the infants at the Charlotte Maxexe Johannesburg Academic Hospital. At Natalspruit Hospital in Ekhuruleni, 10 children similarly succumbed to a nosocomial (hospital acquired) infection (Bodibe 2010).
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These types of events, with large numbers of children acquiring infections in hospitals are not uncommon, although only a fraction grabs the headlines. Outbreaks occur at regular intervals at hospitals throughout the country. An outbreak of Klebsiella infection was responsible for 110 babies dying at Mahatma Gandhi Hospital in Durban, according to the organisation "Voice" that threatened a class action case against the Department of Health. The national health department itself has identified infection control as one of six key areas that needed improvement in the public health sector (Department of Health 2010).
Poor health care at several Eastern Cape hospitals left more than 140 children dead in one of South Africa's poorest districts within the first three months of 2008 (Thom 2008). A task team investigating these deaths in the Ukhahlamba district concluded that they were not the result to any particular disease outbreak or exposure to contaminated water as initially suspected, but rather that the health service available was hopelessly defective. (Report on childhood deaths, Ukhahlamba District, Eastern Cape)
The Ukhahlamba task team, comprising of three experienced public sector paediatricians, painted a grim picture of Empilisweni Hospital children's ward where most of the deaths occurred. Problems identified included:
The structure and layout of the physical facility was inappropriate - no nurse's station or work surfaces, no separation of "clean" and "dirty" areas and no play or stimulation facilities,
The ward and cubicles were overcrowded and no provision existed for lodger mothers, who paid R30 to sleep on the floor next to their children,
There were grossly inadequate services - no oxygen and suction points, too few electrical sockets, no basins or showers and too few toilets in the patient ablutions, and an unacceptable ward kitchen,
Extremely limited clinical equipment,
Staffing deployment and rotation did not promote effective care, with few nurses dedicated to the children's ward and doctors changing wards every two months, leaving the ward devoid of experienced personnel,
There were limited policy documents and no protocols or access to appropriate clinical reference material or guidelines,
Clinical practices were ineffective or dangerous, particularly regarding infection control and the preparation and distribution of infant feeds and medicines,
Not a single hospital record included details about the prescribing or administration of infant feeds. Fluid management was badly documented. Three of the children appeared to have died from fluid overload due to inappropriate and unregulated fluid administration,
The majority of the children were never weighed, their nutritional status was not assessed nor their HIV status established.
The task team's audit of 45 of the deaths revealed that most of the deaths occurred within the first 48 hours of admission to hospital and were in infants who were self-referred. The dominant diagnoses were diarrhoeal disease, pneumonia and malnutrition. The task team concluded that "These deaths are more likely the result of poor care of a vulnerable impoverished community with high rates of malnutrition among the infants and poor utilisation of the available health services."
The pathetic situation described at Empilisweni Hospital is not unique and similar abject conditions can be found at many of the paediatric wards at the 401 hospitals in the country. While objective evidence to support this contention does not exist, paediatric practitioners in many provinces and settings would readily acknowledge the veracity of the claim.
The explanation offered by different investigations of adverse events occurring at public hospitals countrywide is remarkably similar. Uniformly, there is a combination of overcrowded wards, understaffing, overwhelming workloads, a breakdown of hygiene and infection control procedures, and management failure with a lack of auditing or monitoring systems to identify and respond to problems at an earlier stage.
Increasing child mortality
What is not contentious is that South Africa is one of only 12 countries where childhood mortality increased from 1990 to 2006 (Children's Institute 2010), with a doubling of deaths in children under the age of five years in this period (from approximately 56 to 100 deaths per 1000 live births). The 2010 UNICEF State of the World's Children estimates South Africa's under 5 death rate to be 67 per 1000 for 2008 (UNICEF 2009). This high rate ranks South Africa 141st out of 193 countries. The national statistic also hides marked interprovincial variations; from about 39 per 1 000 in the Western Cape to 111 per 1 000 in the Free State (McKerrow 2010). A single disease - HIV- is largely responsible for the increased mortality.
Countries with a similar economic profile (Gross National Income [GNI]) as South Africa such as Brazil and Turkey boast about four-fold lower under 5 mortality rates (U5MR). South Africa's high U5MR is even more disconcerting when compared to poorer countries such as Sri Lanka and Vietnam. These two countries' U5MRs are roughly five times lower (15 and 14 per 1,000 respectively) despite having a GNI less than one half to a third of South Africa's (UNICEF 2009, World Bank 2010).
Despite being classified as a high middle income country, South Africa has high levels of infectious diseases such as diarrhoea, pneumonia, HIV, tuberculosis and parasitic infections normally found in poorer countries. Similarly, there has been little success in reducing undernutrition in children - a quarter of South Africa's children are stunted (short). Further, as a result of increased urbanisation and economic development, the country is also experiencing increasing levels of traumatic injuries and chronic diseases of lifestyle such as obesity, diabetes and cardiovascular disease that are more typical of better resourced countries. These diseases mainly affect adult populations but are increasingly being identified in children.
The worsening in child health has occurred despite significant improvement in children's access to water, sanitation and primary health services. Almost 3000 new clinics have been built or upgraded since 1994, health care is provided for free to children under 5 years and pregnant women (Saloojee 2005), and the child social support grant is reaching 10.5 million children (more than half of all children in the country) (Dlamini 2011). These achievements have been marred by several shortcomings. Many new clinics and the district health systems are not yet adequately functional because of a lack of personnel and finances, poor administration, and expanding demands. Public tertiary health care (academic hospital) services have severely eroded.
Characterising the crisis
The World Health Organization, in 2000, ranked South Africa's health care system as the 57th highest in cost, 73rd in responsiveness, 175th in overall performance, and 182nd by overall level of health (out of 191 member nations included in the study) (World Health Organization 2000). What explains this dismal rating? Despite high national expenditure on health, inequalities in health spending, inefficiencies in the health system and a lack of leadership and accountability contribute to South Africa's poor child health outcomes.
Hospitals operate within a dysfunctional health system
Poor hospital care is but one marker of a dysfunctional health system that comprises blotches of independent services rather than a coherent, co-operative approach to delivering health care. Most primary health care services for children are only offered during office hours, with some clinics restricting new patients' access to services by early afternoon - a waste of available and expensive human resources. Some clinics lack basic diagnostic tests and medication. Consequently, many hospital emergency rooms are flooded with children with relatively minor ailments because their caregivers choose not to queue for hours at poorly managed local clinics, or prefer accessing health services after returning from work.
The referral system in which patients are referred from clinics to district, regional or tertiary hospitals according to how serious their health problems are has disintegrated in many parts of the country. Children who require more specialised care often cannot get it either because they get stuck within a dysfunctional system or because there is no space for them at the next level of care. Transport to secondary and tertiary level hospitals is problematic, resulting in delays or non-arrival, increasing the severity of the disease and treatment costs when the child does arrive.
District hospital services are the most dysfunctional (Coovadia 2009), with patients often by-passing this level of care in settings where access to secondary (regional) or tertiary care (specialist) services are available. Despite cut-backs in budgets, tertiary care settings continue to attempt to provide 'first-class' services, which although commendable, may result in over-investigation and treatment, and denial of essential care to children who reside outside their immediate catchment areas (because the hospital is 'full').
Changing health environment
Some of the increasing stress faced by the public hospitals may be attributed to the changing health environment in which they operate. Two factors are most responsible for the change: rapid urbanisation and the AIDS epidemic. Urban, township hospitals are particularly affected by the burden of increased patient loads, and barely coping with the demand.
Although a national strategic plan for HIV/AIDS exists, the ability to implement the plan is constrained by the enormous demands on human and fiscal resources demanded for its implementation. The budget allocated to HIV/AIDS has increased from R4.3 billion in 2008 to an estimated R11.4 billion in 2010 (13% of the total health budget) (Mukotsanjera 2009). New initiatives aimed at strengthening the HIV/AIDS response, include a national HIV counselling and testing campaign and the decentralization of antiretroviral treatment from hospitals to clinics with nurses now providing the drugs. About a third of children at most South African hospitals are HIV infected. HIV-positive children are hospitalised more frequently than HIV-negative children (17% compared to 4.7% hospitalised in the 12 months prior to the study) (Shisana 2010). Children with AIDS tend to be sicker and often require longer admissions despite suffering from the same spectrum of illnesses as ordinary children.
Greater numbers of patients, higher disease acuity levels and complications, and slower recovery rates all impact on limited resources. High mortality rates take an emotional toll on doctors and nurses. Hospital paediatrics, which has always been a popular and rewarding choice for newly qualified doctors because of modern medicine's ability to quickly restore desperately ill children to health has now become much more about chronic care delivery because of the high number of HIV infected children in the wards, many of whom are re-admitted regularly because of recurrent infections. In recent years, young doctors have been dissuaded from selecting primary care disciplines, such as paediatrics, and have moved instead to pursuing specialities where contact with patients is limited, such as radiology, for fear of acquiring HIV from work-related accidents such as needle-stick injuries. The availability of highly active antiretroviral therapy to increasing number of children nationally, though still limited to fewer than half of all eligible children, has the potential to return paediatrics to its previous status as a rewarding and fulfilling specialty.
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Inequities and inequalities abound in South African health care spending generally, and specifically regarding children's health. Of the R192 billion spent on health care in 2008/09, 58% was spent in the private sector (Day 2010). Although this sector only provides care to an estimated 15% of children, two-thirds of the country's paediatricians service their needs (Colleges of Medicine of South Africa 2009). Furthermore, of the R90 billion provincial public health sector budget, about 14% is spent on central (tertiary) hospital services (Day 2010), which primarily benefits children residing in urban settings and wealthier provinces such as the Western Cape and Gauteng. Similarly, marked inequities exist in the number of health professionals available to children in different provinces with, for example, one paediatrician servicing approximately 8,600 children in the Western Cape, but 200,000 children in Limpopo (Colleges of Medicine of South Africa 2009). This differential exists among most categories of health professionals.
The current health system claims to provide universal coverage to children. Yet, from a resourcing, service delivery and quality perspective, the availability and level of service is inequitable with many patients and communities experiencing substantial difficulty in accessing the public health system. Rural and black communities remain most disadvantaged.
Apartheid age differentials continue in present day health care. Thus, for instance, while the formerly whites only Charlotte Maxexe Johannesburg Academic Hospital now mainly serves a black urban population, its resources including ward facilities, staff-patient ratios and overall budget still show a clear positive bias when compared to the resources available to the Chris Hani Baragwanath Hospital located in Soweto (a former 'black' hospital) (von Holdt 2007). Nationally, the most stressed hospitals are those with the lowest resources per bed. The least stressed hospitals continue to be those with previous reputations as high-quality institutions (mostly previously "whites only" hospitals) that provide them with a kind of 'social capital' (von Holdt 2007).
Management capacity crisis
The battle for the control of hospitals
South Africa has embraced the concept of health services delivered within a three-tiered national health system framework - national, provincial and district. Provinces are charged with the responsibility of providing secondary or tertiary hospital services, with district services having responsibility for district hospitals and clinics. Existing legislature allows hospital chief executive officers (CEOs) considerable powers in the running of their own hospitals.
However, there is a dysfunctional relationship between hospitals and provincial head offices, which often assume authoritarian and bureaucratic control over strategic, operational and detailed processes at hospitals but are unable to deliver on these. There is a blurred and ambiguous locus of power and decision-making authority between hospitals and head offices (von Holdt 2007). Hospital managers are disempowered, cannot take full accountability for their institutions and are mostly unable to decide on matters such as staff numbers and appointments, drawing up their own budgets or playing any role in the procurement of goods and services.
The structural relationship between province and institution is a disincentive for managerial innovation, giving rise to a hospital management culture in which administration of rules and regulations is more important than managing people and operations or solving problems, and where incompetence is easily tolerated. Hospital managers' lack of control undermines management accountability and promotes subservience to the central authority. The role of provincial health departments should really be about controlling policy regarding training, job grading and accountability.
Silos of management
Most South African hospitals have essentially the same management structure where authority is fragmented into separate and parallel silos. Thus, doctors are managed within a silo of clinicians, nurses within a nursing silo, and support staff by a mesh of separate silos for cleaners, porters, clerks, etc. The senior managers in the institutions have wide spheres of responsibility but with little authority to make decisions or implement them (von Holdt 2007).
As an example, a clinical department such as paediatrics is headed by a senior or principal paediatric specialist who has no control over the nurses in the paediatric department. In the wards, nursing managers are responsible for effective ward functioning, but have little control over ward support staff such as cleaners or clerks. A senior clinical executive (superintendent) has responsibility for the paediatric (and other) departments, but can exercise little substantial authority over it because power lies within each of the silos (doctors, nurses, support workers). As a result, the clinical executive has to attempt to negotiate with all parties.
Doctors and nurses do not determine budgets, or monitor and control costs. In essence, those responsible for using resources have no influence on their budgetary allocation, while those responsible for the budget assume no responsibility for the services that the budget supports. Most clinical heads have no idea what their budgets are and costs are not disaggregated within the institution to individual units or wards.
Thus, what should be managed as an integrated operational unit (for example, a ward or clinical department) operates instead in a fragmented fashion with little clear accountability. In this circumstance all parties are disempowered, and relationships oscillate between diplomacy, persuasion, negotiation, angry confrontation, complaint and withdrawal. In the process few problems are definitively resolved, with negative consequences for patient care. Where institutional stress is high, the fragmented silo structures generate the fault lines along which conflict and managerial failure manifest (von Holdt 2007).
Insufficient expenditure on health, hospitals and child health
Between 1998 and 2006, South African annual public per capita health expenditure remained virtually constant in real terms (i.e. accounting for inflation), although spending
in the public sector increased by 16.7% annually between 2006 and 2009 (National Treasury 2009). Nevertheless, the small increases in expenditure have not kept pace with population growth, or the greatly increased burden of disease (Cullinan 2009). In 2009 the country spent 8.9% of the gross national product (GDP) on health (Day 2010), and easily met the World Health Organisation's (WHO) informal recommendation that so-called developing countries spend at least 5% of their GDP on health (World Health Organization 2003). However only 3.7% of GDP was spent in the public sector, with 5.2% of GDP expended in the private sector (Day 2010). In per capita terms R9605 was spent per private medical scheme beneficiary in 2009, while the public sector spent R2206 per uninsured person (Day 2010).
Although the health of mothers and children has been a priority in government policy since 1994, including in the latest 10 Point Plan for Health (Department of Health 2010), it has not translated into movements in fiscal and resource allocation. Children comprise nearly 40% of the population (Statistics South Africa 2009), but it is unlikely that a similar proportion of the health budget is spent on child health. No reliable data exist, as government departmental budgets do not specifically delineate expenditure on children, easily allowing this constituency to be short-changed or ignored.
Poor fiscal discipline
A lack of accountability extends throughout the health service, and includes the lack of fiscal discipline. Provincial departments of health collectively overspent their budgets by more than R7.5bn in 2009/10 (Engelbrecht 2010). Provincial departments frequently fail to budget adequately, resulting in the freezing of posts and the restriction of basic service provision (e.g. routine child immunisation services were seriously disrupted in the Free State province in 2009 [Kok D 2009]). Every year, budgetary indiscipline results in critical shortages of drugs, food supplies and equipment in many provinces, particularly during the last financial quarter from January to March, and during April when new budgetary allocations are being released.
"Stock-outs" of pharmaceutical agents, medical supplies such as disinfectants or gloves or radiological material, and food or infant formula, may annoy staff but may have devastating consequences for patients, including death. Most of these "stock-outs" are the result of suppliers terminating contracts because of failure of payment of accounts. In Gauteng, medical suppliers are currently owed more than half a billion rand by the Auckland Park Medical Supplies Depot, the central unit from which medicines are distributed to provincial hospitals and clinics. The largest amounts owed by the depot are to two pharmaceutical companies (some R130 million) (Bateman 2011).
A recent embarrassing occurrence is the return of R813 million to Treasury at the end of the past financial year by the health department because of unspent funds (Bateman 2011). Most of the money was budgeted to revive collapsed and unfinished infrastructure at hospitals. This function belongs to the Department of Public Works, and hospitals have little influence on the functioning of this separate department - a further example of fragmented services. Treasury has nevertheless allocated funds for the revival or construction of five academic hospitals by 2015, mainly through public private partnerships. These are Chris Hani Baragwanath in Soweto, Dr George Mukhari in Pretoria, King Edward VIII in Durban and Nelson Mandela in Mthatha, as well as a new tertiary hospital for Limpopo.
Provincial health departments are beginning to show modest success in rooting out fraud and corruption, but their efforts have revealed widespread swindling costing taxpayers billions of rands, much of it deeply systemic (Bateman 2011). The bulk of endemic corruption involves dishonest service providers with links to key health department officials, looting via ghost and multiple payments loaded onto payment systems. In the Eastern Cape an external audit of 'anomalies' in four health department supplier databases revealed R35 million in duplicate or multiple payments in 2010 (Bateman 2011). Some 107 suppliers had the same bank account number, 4 496 had the same physical address and 165 suppliers shared the same telephone number. Less sophisticated fraud involved the bribing of district ambulance service directors to transport private patients.
Theft of equipment, medication and food is pervasive, aggravating existing bottlenecks in supply chain management. Almost R120 000 worth of infant formula destined for malnourished babies or infants of HIV-positive mothers was stolen in the Eastern Cape in 2010 for which three foreign national businessmen and four health department officials were arrested. Eight nurses at Mthatha's Nelson Mandela Academic Hospital were arrested for allegedly stealing R200 000 worth of medicines (Bateman 2011).
In KwaZulu-Natal, a report to the finance portfolio committee revealed 24 'high priority' cases involving irregularities, supply chain and human resource mismanagement, overtime fraud, corruption, nepotism, misconduct and negligence, amounting to nearly R1 billion. Among others, the former health MEC, Peggy Nkonyeni faced charges of irregular tender awards amounting to several million rands (Bateman 2011).
Ten health department officials in Mpumalanga, including its chief financial officer, appeared before a disciplinary tribunal on charges of corruption. Three separate probes uncovered massive fraud and corruption in the department, including irregularities with tender procedures and the buying of unnecessary hospital equipment. Perversely, Sibongile Manana, the health MEC, was removed from her post by the provincial Premier, and given the Sports, Recreation, Arts and Culture portfolio. The Premier justified this decision by claiming that the reshuffle of his executive council was to rectify 'instances of mismanagement and wrongdoing' uncovered by a series of forensic audits (Bateman 2011).
Human resources crisis
Staff shortages are a critical problem in most public hospitals, and are the result of underfunding as well as a national shortage of professional skills. Almost 43 % of health posts in the public sector countrywide are vacant, and more concerning appear to be increasing (up from 33% in 2009 and 27% in 2005) (Lloyd 2010). Some institutions are running with less than half the staff they need, with more than two-thirds of professional nurse posts and over 80% of medical practitioner posts in Limpopo unfilled (Lloyd 2010). Shortages of support workers such as cleaners and porters exacerbate the problem, since nurses and doctors end up performing unskilled but essential functions.
Shortages of nurses in particular are generating a healthcare crisis in South African public hospitals (von Holdt 2007). Nurses have a wide scope of practice, and bear the brunt of increased patient-loads, staff shortages and management failures. Ironically, a number of nursing colleges were closed down in the late 1990s as part of government's cost-cutting measures while government made it very difficult for foreign doctors to practice in the country. The situation is now being addressed with recognition of the need for both more nurses and doctors to be trained. However, the constricted resources available limit a speedy or meaningful response and considerable investment in new facilities and trainers is required over the next decade to address the current deficit.
Throughout the country, doctors and nurses constantly make decisions about which patients to save and which to withhold treatment from based on available staff and physical resources, rather than medical criteria. Because of the pressure on beds, children are sometimes denied admission to hospitals, not referred appropriately or discharged prematurely, thus facing the danger of deterioration, relapse or death.
Conditions of service
Understaffing and vacant professional posts and are the result of a number of factors, and vary in different locations. They include failure to establish new posts despite the increased demand for services, 'frozen posts' because of insufficient funding being available and lack of suitably qualified staff. This lack may be because of "pull" or "push" factors. "Pull" factors attract staff away from the public service and include emigration and movement to the more lucrative private sector. "Push" factors such as poor salaries, the inability of hospitals to satisfy the simple creature comforts of staff, particularly in rural or township settings, and a blatant disrespect by hospital administrators of the professional status of staff induce staff to leave the public service. The high death rate of health workers from AIDS has further exacerbated the skills crisis.
The Occupational Specific Dispensation was a measure introduced to specifically address the poor salaries paid to nurses and doctors. Although the intervention has been successful in retaining some staff in public sector hospitals and even enticing private sector nurses and doctors back, this financial incentive was insufficient to prevent national strikes by both doctors in 2009 and the entire health sector in 2010. Much of the dissent and unhappiness related to conditions of service, rather than the declared dispute about the size of the annual increase of the pay package. The long and bruising six-week strike was a sad indictment of the poor levels of professionalism of health workers, with wards full of newborn and young infants in many hospitals being abandoned instantly and completely with no interim plans for their feeding or care. This necessitated emergency evacuations or alternative arrangements by practitioners who were willing to place their little patients' needs above those of the strike action, and by concerned members of the public. Undoubtedly, many hundreds of children's lives were lost during this industrial action but the details of these deaths and any consequent punitive action has been conveniently ignored in an attempt to placate further strike action by the responsible parties.
Aberrant staff behaviour
Absenteeism among health workers is rife, even at well run institutions such Durban's Addington Hospital (Cullinan 2006). This is mostly due to stress, but nurses "moonlighting" in private hospitals to supplement their state salaries is also a factor. At hospitals where management was weak, such as Cecilia Makiwane Hospital in East London or Prince Mshiyeni in Durban, nurses also turned up late, left early, and often neglected patient care such as regular monitoring of vital signs (Cullinan 2006). Hospital managers' ability to take disciplinary action is severely limited by the centralised nature of provincial health bureaucracies. In many provinces, the provincial head of health is the only person able to dismiss staff.
Hospitalised children are the most vulnerable, since they cannot demand services or advocate for their own needs. Thus missed feeds, failure to receive prescribed medication timeously or missed doses, inattention to monitoring vital signs and delays in responding to sudden clinical deterioration are daily occurrences in children's wards countrywide.
Service delivery crisis
Inadequate patient care
There is a crisis of caring at hospital throughout the country. Evidence of poor service delivery at hospitals is disputed, ignored, and mostly tolerated by readily accepting the excuse of low staff morale, staff or resource shortages and 'no money' (Saloojee 2010). The caring ethos that characterises the health profession has eroded to the degree that most patients are grateful for any acts of kindness directed to them. Many patients can recount how their most basic needs, such
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